The contribution of community health systems to resilience: Case study of the response to the drought in Ethiopia

Background Ethiopia’s exposure to the El Niño drought (2015-2016) resulted in high malnutrition, internally displaced people, and epidemics of communicable diseases, all of which strained the health system. The drought was especially challenging for mothers and children. We aimed to identify salient factors that can improve health system resilience by exploring the successes and challenges experienced by a community-based health system during the drought response. Methods We collected data via key informant interviews and focus group discussions to capture diverse perspectives across the health system (eg, international, national, district, facility, and community perspectives). Data were collected from communities in drought-affected regions of: 1) Somali, Sitti Zone, 2) Hawassa, Southern Nations, Nationalities, and Peoples’ Region (SNNPR), and 3) Tigray, Eastern Zone. Data were analysed using a deductive-inductive approach using thematic content analysis applied to a conceptual framework. Results A total of 94 participants were included (71 from the communities and 23 from other levels). Key themes included the importance of: 1) organized community groups linked to the health system, 2) an effective community health workforce within strong health systems, 3) adaptable human resource structures and service delivery models, 4) training and preparedness, and 5) strong government leadership with decentralized decision making. Conclusions The results of this study provide insights from across the health system into the successes and challenges of building resilience in community-based health systems in Ethiopia during the drought. As climate change exacerbates extreme weather events, further research is needed to understand the determinants of building resilience from a variety of shocks in multiple contexts, especially focusing on harnessing the power of communities as reservoirs of resilience.

In 2003, the Ethiopian government implemented the Health Extension Program (HEP), which deployed Health Extension Workers (HEWs) to strengthen community-based health systems in rural populations [8]. HEWs are paid government employees based partly in communities and in health posts, with diverse roles and responsibilities in some regions. They are supported in their position by community groups such as the health development army volunteers (HDAVs), which are comprised of community women who have demonstrated exemplary health behaviours.
The HEW program has demonstrated mixed results in improving MNCH care in Ethiopia. While visits from HEWs positively influenced antenatal care (ANC) utilization, there has been little or no improvement in facility birth rates or coverage of essential newborn care, despite increases in deliveries attended by skilled birth attendants [9][10][11][12]. Some studies in the postnatal period have indicated that health care utilization increased with the presence of HEW programs, while others found no impact [9,10,13]. Similarly, no impact was observed for integrated community case management (iCCM) of childhood illness, despite the high quality of care provided by HEWs [14].
Limited health service utilization and low numbers of household visits by HEWs have been reported as barriers to the success of the HEW program [13,15]; ongoing low immunization coverage [16] and inequities in MNCH service delivery [17] make it critical for understanding how HEWs and the communities they serve can best be leveraged to build resilience in health systems, especially in times of shock.
Building resilience in health systems has garnered increasing attention considering new and emerging threats or shocks to health systems globally, many of which have occurred simultaneously or in succession (eg, Ebola Virus and COVID-19, natural disasters, economic and security crises). However, the lack of clarity in the conceptualization of resilience (and how to operationalize it) remains a challenge [18]. Resilience has been defined by Kruk et al. [19] as the "capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it". Some describe resilience as an emergent property which frames health-related challenges within a systemic approach that recognizes the dynamic and interconnected nature of health systems [20][21][22]. Others warn that the resilience paradigm promotes a form of neoliberal governmentality which places the responsibility to "bounce back" from crises on individuals and communities while ignoring the political forces shaping the crisis [23,24]. Advocating a health system "bounce back" to states of structural weakness and social inequalities may hide a potentially deficient status quo [25,26]. The drought response in Ethiopia provides a unique opportunity to add to the evidence base for health system resilience by examining the successes and challenges experienced across the health systems in the country. Such evidence could inform efforts to strengthen health systems and help build resilience through maximizing resources and support for improved maternal and child health, both in times of crisis and beyond.
We aimed to identify salient factors that can improve health system resilience by exploring the successes and challenges experienced by a community-based health system during drought response. Sub-objectives included understanding barriers and facilitators to community engagement and participation in the health system at the community level and barriers and facilitators to HEWs' effectiveness, including how their role changed from before the drought to during the drought response, especially in the provision of MNCH services.

METHODS
Focus group discussions (FGDs) and key informant interviews (KIIs) were conducted to meet the objectives. FGDs were employed primarily at the community level while KIIs were conducted mostly at the district, sub-national, or national levels. This study was part of a four-country study on building resilience in community-based health systems.

Data collection, participant recruitment and selection
The UNICEF country office, in partnership with the Federal Ministry of Health (FMOH), identified three diverse drought-impacted geographic areas for the community-level data collection: 1) Sitti Zone, Somali Region, 2) Hawasa Zone, Southern Nations, Nationalities, and Peoples' Region (SNNPR), and 3) Eastern Zone, Tigray Region. These zones were selected to gain diverse insights on health system-related challenges in the various regions of Ethiopia. We purposively selected areas that had recently experienced drought to include agrarian and developing regions (those with limited infrastructure) and urban, peri-urban, and rural areas.
Purposive sampling was used to identify the first round of participants. Participants were then recruited via snowball sampling by UNICEF staff members with the goal of capturing diversity across the health system (ie, from lowest to highest level and key players within these levels) and geographically. Community-level participants included HEWs, village and community leaders, women's HDAVs, primary health care unit (PHCU) health workers, and mobile health and nutrition unit staff. Non-community participants included district health staff and management, FMOH representatives, multilateral health organizations, bilateral development partners, and international non-governmental organizations (NGOs). Participants were approached in person or by phone and were read a script, informed about the goals and research team, and given the opportunity to ask questions. All participants provided written informed consent. In cases where participants were illiterate or had low literacy, consent forms were read to them, and thumbprints were collected in lieu of signatures.
The conceptual framework guiding this research was a modified health system performance framework [27] with modifications informed by Tanahashi Bottleneck analysis [28], current literature, and expert input from the country and international levels. Sub-objectives of the study included understanding the following phenomena related to building resilience in CBHS with respect to the drought: impact of the drought on HEWs and health system, community engagement and participation, service delivery, adaptability, and preparedness. Semi-structured guides with open-ended questions were developed and used for FDGs and KIIs. The guides were not validated or pilot tested. Guides were tailored to the participant's knowledge or role in the health system. Data were collected in the participants' languages of preference (ie, English, Afsomali, Amharic, or Tigrinya) and facilitated by semi-structured interview guides. For non-English speaking participants, we employed simultaneous translation conducted by a UNICEF staff member or community-level health worker. This allowed for in-depth probing and feedback between the participants and the researcher. FGDs were approximately 1 hour in length while KIIs lasted between 30-45 minutes. All interviews were audio recorded with participants' permission, transcribed verbatim, and translated into English. Translations were checked for accuracy by UNICEF team members but were not returned to participants for verification. There was no prior relationship between data collectors and participants. Data collection occurred in October 2016.

Analysis
Data were analyzed using a deductive-inductive approach which began with first-level coding of verbatim English transcripts in ATLAS.ti software [29]. Open codes were defined by the sub-objectives and conceptual framework of the interview guide. We identified emerging themes using content analysis embedded in a grounded theory approach, chosen for its ability to identify the interconnectedness of the data and areas of conflict and contradiction. Thematic content analysis began by open-coding data on the first level to identify successes and challenges or facilitators and barriers related to three a priori domains: 1) HEWs and resilience during shocks (drought), 2) community engagement and participation, and 3) service delivery and HEWs. Emerging themes were synthesized based on community and non-community perspectives to examine the differences and similarities between these two perspectives. The co-authors discussed potential differences in the application of a priori and emerging themes to reach a consensus on classification. Data were triangulated using method triangulation [30] across sub-objectives to identify salient themes that were discussed in building resilience in community-based health systems.
Ethical approvals were obtained through the University of British Columbia Behavioural Research Ethics Board (certificate H1502651) and the Ethiopian Public Health Institute Scientific and Ethical Review Committee (certificate SERO-016-9-2016).

Participant Description
A total of 94 people participated in this study, including 71 from the community and 23 from the non-community level ( Table 1). Non-community participants were included among District (Woreda) and Ministry of Health representatives, UNICEF country office team members, and other partners (bilateral, multi-lateral, and international NGOs). More than 40% (n = 10) of non-community participants were from the district (Woreda) level. The largest group of participants from the communities were from the women's groups at 37% (n = 26). Of the 71 community participants, 21 (29.5%) were from Somali, Sitti Zone, 19 (26.8%) from Hawassa, SN-NPR, and 31 (43.7%) were from Tigray, Eastern Zone ( Table 2).
Participants identified several themes regarding building resilience in community-based health systems during the drought response in Ethiopia.

Organized community groups linked to the health system via the primary health care unit
First, participants felt community groups that were well organized, active, and engaged with the health system facilitated a successful and timely drought response. Participants discussed how community groups identified problems and solutions during the drought response, alerted decision-makers on the changing needs of the communities, conducted surveillance, mobilized and educated communities, and held the health system accountable to meet their needs. Participants felt that strong community groups allowed for quick information exchange with the health system and improved self-reliance, lessening communities' dependence on government support during the drought response (Quotes 1 and 2, Table 3). The advantages of strong communication networks and feedback mechanisms between the community groups and the health system were widely discussed. Participants felt regular meetings improved accountability to communities and provided pathways for communities to communicate their needs, thereby ensuring a more effective response (Quote 3, Table 3). Many participants felt community-led initiatives were more successful because they were implemented with community buy-in and in coordination with health workers and facilities (Quote 4, Table 3).
Participants also described challenges for community groups during the drought response, which included competing community priorities and resources, the need to improve accountability, and top-down programming. Many participants felt communities had shifting or competing priorities during the drought response (eg, the need for food or water compromising participation in prevention efforts) which resulted in limited uptake of educational interventions and participation in health programming (Quotes 5 and 6, Table 3). Many community women felt they would have more confidence in the health system and would be more likely to participate if they saw the results of their feedback when their messages were delivered to higher levels of the health system. Non-community participants also discussed challenges in meeting the communities' needs after engagement and described how some programs were imposed on commu-

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UNICEF country office participant Lack of international funding for health system (Challenge) The theory is stronger than the reality or the practice on the ground. Most of the time the partners will give you money for development and give you money for emergency response but there is little money for rehabilitation which will support resilience, preparedness and rehabilitation HEW -health extension worker, PHCU -primary health care unit, HW -health worker, AWD -acute watery diarrhoea Table 3. Continued nities rather than being done in a participatory manner due to the acuteness of shocks. Participants described difficulties in mobilizing resources to meet the communities' needs due to mismatched priorities across partners, especially during a shock such as a drought.

Effective community health workforce within strong health systems
The most widely discussed success of the drought response was the role of HEWs within strong health systems. Many participants described how HEWs' roles prior to the drought were expanded beyond prevention, health promotion, and selective curative health services. These broadened responsibilities included providing drugs, immunisations, reducing newborn sepsis, and treating pneumonia, malaria, and diarrhoea, alongside their roles as community engagers and mobilizers. Examples of community mobilization included organizing and leading community groups, empowering communities, and training community development teams. Participants also described the importance of HEWs in coordinating international partners and donors, identifying those community members in greatest need during the drought response, and providing data in a timely way (Quotes 7 and 8, Table 3).
Participants identified diverse barriers and facilitators to HEWs performing their duties, which fell into broad themes related to populations and communities they served, HEW factors, and health system factors. Many participants felt HEWs experienced increased workloads during the drought and suggested that more HEWs should be hired and that HEWs needed to be better supplied, appropriately trained, given more incentives, and have improved mobility to cover larger distances. Many participants highlighted the importance of strong health systems within which HEWs work, including strong supply chains, committed facility-based health care workers, social support systems, and health service coverage (Quotes 9 and 10, Table 3). Many non-community participants cautioned on a health system's overreliance on HEWs and highlighted the importance of strong health systems before, during, and after a shock.

Adaptable human resource structures and service delivery models
Third, adaptable human resource structures and service delivery models within communities and facilities were discussed as determinants of a successful drought response. Task shifting and teamwork between mobile health units, HEWs, community groups, and facility-based health care workers (HCWs) were discussed as facilitators of resilience. Specific examples included: HCWs working in villages to provide technical support to HEWs, HEWs sharing the workload within communities, HEWs having the flexibility of being based in either facilities or communities as priorities shifted, and HCWs being multiskilled to perform facility duties and outreach activities. Participants felt adaptable human resources improved the ability to respond to multiple shocks concurrently, prevented outbreaks, and increased the geographic reach of health education, promotion, and service delivery. Many participants attributed the health system's ability to absorb increased workloads during the drought to workload redistribution between HEWs and HCWs. This was described as having allowed the health system to meet the increasing demands of communities, expanding networks into communities, and integrating different sectors with strong referral pathways (Quotes 11-15, Table 3). Mobile health units were discussed as an effective, alternative service delivery modality strategy to expand services and target the response to the populations who needed it most. This included pastoralists, those living in hard-to-reach areas, and internally displaced populations. Mobile health units were often discussed as a tool for filling a critical gap to meet the needs of migratory and pastoralist communities who would otherwise not have access to the health system. Lastly, regular meetings between HEWs and facility-based health workers allowed for opportunities to review the effectiveness of interventions and facilitated their ability to respond to the drought.
Challenges related to adaptable human resources included the suboptimal numbers of human resources during the drought and in the health system broadly, especially in remote regions. Participants also felt health centres needed to be well-equipped and resourced to meet the needs of communities, including better supplies, medication, and relief kits. Lastly, some participants also expressed concerns about the sustainability of financing mobile health units beyond the drought response, especially since many were donor-driven.

Training and preparedness
Fourthly, training and preparedness were widely discussed successes during the drought response. Participants felt that training communities, HEWs, and HCWs prior to and during the drought allowed them to respond appropriately and quickly to the needs of communities. This was reported as having lessened the drought's impact on health outcomes, specifically on outbreaks of infectious diseases (Quotes 16-18, Table 3). Many non-community participants discussed the success of using evidence in planning the drought response. Participants described how lessons learned from previous droughts guided the advanced procurement of supplies. HCWs described prevention and mitigation strategies that prepared them for the drought which included drug acquisition and coordination done prior to the drought for reportable diseases (eg, scabies, water-borne diseases). Participants felt the early warning systems and health development plans allowed for evidence to be captured and disseminated quickly. Participants also discussed the successes of identifying the most marginalized villages and prioritizing them with constant evaluation of the gaps in services provided to them. Participants discussed the increased surveillance and strengthened reporting structures as successes that enabled the quick and effective deployment of supplies.
Although many participants discussed the advantages of preparing for anticipated outbreaks, unplanned ones were challenging (eg, dengue, chikungunya, and scabies). Participants felt that training communities and health workers on a wider array of possible threats, especially communicable diseases, would have facilitated a stronger response. Many participants felt there was a need for continuous risk assessment during an emergency to adequately prepare for any shock. Participants also highlighted the need for risk-informed programming, disaster reduction strategies, and policies that could be implemented during the drought response. Participants felt the finances and logistics needed to be in place from the lowest to the highest levels of the health system to adequately prepare for successful drought response.

Strong government leadership with decentralized decision making
Strong government leadership was a widely discussed success of the drought response. Many participants felt the government response was well-coordinated through multiple levels of the health system and across multiple sectors. Participants reported that the successes of the government's response included the provision of financial resources, technical support, capacity building, and other resources to communities. Many participants discussed how the government guided partners to the neediest geographic areas and the advantage of the health sector being the command post where the response with partners was coordinated from higher to lower levels of the health system.
Decentralized decision-making during the drought response was also discussed as a success. Community elders and leaders described the success of communities coming together to decide how to allocate resources received from governmental and international donors. Decentralized decision-making to districts, facilities, and community levels was described to increase adaptability to meet the affected populations' needs. Strong district-level support was also discussed as a facilitator of the response by mobilizing the communities.
Participants also identified challenges to the government response and decentralization. Many non-community participants felt that districts needed more decision-making power and resources for a more timely and effective response. Building district capacity for decision-making was also discussed as a method for fostering resilience. Some participants felt the government was focused on longer-term programming, which was a barrier to quick, adaptable health systems, but highlighted a need for both (Quote 19, Table 3). Many participants highlighted challenges related to differing priorities on the part of the government and international donors, which hindered the donors' abilities to respond to the drought. Some felt the government not declaring an emergency was also a barrier to the international community mobilizing resources for the drought response. Participants also noted difficulties in raising money beyond the emergency response, leading to missed opportunities for rehabilitation, capacity building, and/or strengthening the health system (Quote 20, Table 3).

DISCUSSION
Participants identified several important themes for building resilience in community-based health systems based on their experiences during the drought response in Ethiopia. Major themes included the importance of communities, decentralized health systems, training and multisectoral collaboration. The need for strong and adaptable health systems was highlighted across themes, focusing on features that would allow health systems to meet the needs of populations both in times of crisis and beyond. Community members highlighted the importance of feeling heard by decision-makers and the need for more health workers and resources, as well as ongoing training to enable communities to be prepared and respond quickly to future emergencies. Major priorities for non-community participants included a reduction in over-reliance on HEWs, stronger supply chains, and greater clarity in terms of priorities between governmental and non-governmental actors in crisis response.
Communities and HEWs were central to the success of the response across all themes and building their capacities must be prioritized to respond to various shocks to health systems. HEWs in this context have demon- strated key elements of resilience as defined by connecting the communities with "the people, relationships and local contexts that constitute health systems", but must be further supported and strengthened [31]. This includes increased numbers of HEWs implemented alongside broader health system improvements (eg, investments in health posts, supply chains, information systems, supportive supervision, and strong referral networks) [32]. Additionally, as discussed elsewhere, strong self-reliant community groups linked to the health system can build the community's adaptive capacity to respond to shocks such as cyclic droughts [2,33,34].
Previous research has described lessons learned at the community level during other health shocks (eg, Ebola virus disease), including the need to engage communities early and build trust [35,36]. In contexts where communities were consulted late in the response and in fragmented ways across diverse partners (eg, in Sierra Leone and Liberia during the Ebola virus outbreaks), community trust in the response was limited [36,37]. The Ethiopian health system was uniquely well-placed to engage in these early trust-building activities because community groups and health workforces were supported by the government and engaged relatively uniformly from the inception of the drought response. Despite this, our findings indicate that "top-down" programming, shifting and competing priorities during the drought, and lack of accountability were persistent challenges to building resilience within community health systems.
As we continue to unpack what is meant by building resilience in community-based health systems, there is an urgent need to better understand the intersection of communities and their health systems, as well as how communities' roles can best facilitate resilience. As extreme weather patterns and outbreaks of infectious diseases continue to place increasing pressure on already strained health systems, community groups have a critical role to play in filling important resource and service gaps and in contributing to crisis responses. However, a lack of supervision and incentives for community groups, low perceptions of community inclusiveness, and shortages of community health workers have been linked to decreased service utilization in some regions, especially for MNCH services [8,38].
Well-resourced, supported, and trained health personnel have been identified as key in resilient health systems, with the World Health Organization stating "resilient health systems can only be achieved with a strong health workforce" [39]. Therefore, to build resilience in community-based health systems, we recommend investments in communities, especially the community health workforce and community groups.
Decentralized decision-making and training were often discussed as determinants of resilience. Communities where initiatives were led at the local-level (as opposed to top-down responses) were described as more empowering and effective in this context. With districts having the decision-making power to reallocate resources as needed while being supported by well-trained individuals and groups, communities could address a broad range of threats. Flexibilities in resource allocation would allow for rapid scale-up of acute drought responses in areas where they are most needed. Building resilience moved beyond the health sector, with intersectoral engagement also playing a key role in building resilience by addressing population needs such as food and water. The importance of this preparedness and flexibility in enabling an agile emergency response is particularly relevant considering the COVID-19 pandemic. Despite lessons from previous shocks, where preparedness was key for a successful response and continuation of essential services, the COVID-19 emergency response was woefully inadequate [40,41] and resulted in major disruptions to other areas of the health system, including the provision of services for HIV, malaria, and tuberculosis [40]. In a review of preparedness and response plans from 106 countries, considerations for subnational non-COVID essential health service delivery were only present in 34% of countries and less than half had included a mechanism that considered health system-wide services in their emergency planning [41]. As emergent health threats of pandemic potential continue to arise in the years ahead, planning and preparedness with communities across health systems must be prioritized, with a key focus on community health workforce and community groups.
Our study has several strengths and limitations. A major strength was that, to our knowledge, this is the first study to explore the drought response in building resilience in CBHS from diverse geographic regions and communities in Ethiopia. This allowed us to document relevant themes across communities and experiences. The diversity in participants across the health system fostered our understanding of the drought response from a cross-cutting health system perspective. We limited recall bias by interviewing participants during the drought crisis. However, there are some limitations to our study and the applicability of the findings. Our findings may not be generalizable to other regions of Ethiopia besides the three included in our study. Additionally, we may have captured themes related to the drought response at the specific time of our study. As the drought continued, the ongoing impact on workloads and resources may have resulted in different findings. Lastly, in areas with historical tension with the government, and given the political climate in Ethiopia, it is possible some respondents were not entirely forthcoming in their responses, which could have led to a reporting bias. www.jogh.org • doi: 10.7189/jogh.12.14001

CONCLUSIONS
Building resilience in community-based health systems during the drought in Ethiopia was facilitated by strong communities and community health workforces within health systems that were adaptable to the population's needs. Further research is needed to understand the determinants of building resilience from various types of shocks in multiple contexts, especially focusing on harnessing the power of communities as reservoirs of resilience. There is an increasingly urgent need to move our understanding of resilience from theory to operationalization as our changing world will need to respond to crises.